Basic Information
Provider Information | |||||||||
NPI: | 1578710612 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAN GABRIEL VALLEY IMAGING PARTNERSHIP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VALLEY IMAGING PARTNERSHIP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 635 | ||||||||
Address2: |   | ||||||||
City: | WEST COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917930635 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6268139988 | ||||||||
FaxNumber: | 6268130049 | ||||||||
Practice Location | |||||||||
Address1: | 1115 S SUNSET AVE | ||||||||
Address2: |   | ||||||||
City: | WEST COVINA | ||||||||
State: | CA | ||||||||
PostalCode: | 917903940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6268142473 | ||||||||
FaxNumber: | 6268142540 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2008 | ||||||||
LastUpdateDate: | 03/16/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KAISERMAN | ||||||||
AuthorizedOfficialFirstName: | DONALD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6268139988 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | GR0058270 | 05 | CA |   | MEDICAID |